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A Journey to the Designation of Baby-Friendly Maternal and Child Health Centres
Dr Annie Fok Oi-ling
BFMCHC Co-ordinator, Family Health Service, Department of Health
In Hong Kong, Maternal and Child Health Centres (MCHCs) provide the continuum of care that supports mothers to optimally feed and care for their babies. Most MCHCs provide antenatal services in collaboration with the Obstetric Department of hospitals under the Hospital Authority, and health promotion and disease prevention services for children from birth to 5 years.
The Queen Elizabeth Hospital and Queen Mary Hospital have been the pioneers in working towards Baby-Friendly Hospitals since 2013.1 Having antenatal shared-care with these two hospitals, Kowloon City MCHC, Sai Ying Pun MCHC and Yaumatei MCHC were thus chosen as the pilot centres to work towards Baby-Friendly MCHCs (BFMCHCs) in June 2016. Their achievements have been recognised and they were awarded the Baby-Friendly status in July and August 2019.1
Beyond the Intent to Protect, Promote and Support Breastfeeding
“Let’s start from here, lose the past and change our minds”
Implementation of the “Ten Steps to Successful Breastfeeding” and “International Code of Marketing of Breastmilk Substitutes” with subsequent relevant WHO/WHA resolutions, where applicable, in MCHCs has long been adopted as the Breastfeeding Policy of the Department of Health (DH).2 Achieving Baby-Friendly designation appeared possible, and perhaps even simple.
The Baby-Friendly Initiative Working Group (BFI WG), consisting of a team of doctors, nurses and a scientific officer, was established in 2016. This central BFI team played a key role in co-ordinating, planning, training and monitoring, as well as working in collaboration with the pilot BFMCHCs staff. The Certificate of Intent was applied when all the staff were ready, and was awarded in June 2016.
Self-appraisals of the Pilot BFMCHCs were then conducted to identify the gaps in meeting the standards as stated in the BFMCHC Designation criteria3 (Annex 1). It did not take us long to appreciate that BFI went beyond breastfeeding. It encompassed enabling parents to develop close, loving relationships with their babies and supporting newborns who are not breastfed.
In sum, BFMCHCs prepare expectant and new parents to care for and feed their infants in ways which support optimal health and well-being. We have to widen our perspective to embrace the principles of Baby-Friendliness, and transform them into actions in our daily work.
Implementing the Infant Feeding Policy (Annex 2) and Action Plan
“We thought we had already been doing well on breastfeeding at the MCHCs, but were astonished to find that a lot more could be done. But how?”
When planning to implement the BFMCHC policy standards, we made reference to the UK BFI standards, which had been expanded to include enhanced staff communication skills, responsive feeding, supporting all parents to build close and loving relationships with their babies and enhanced support for parents who are formula feeding their babies.4
Our focus was client-centric and operationally proficient whilst incorporating the Infant Feeding Policy standards into our services.
The Gaps and Challenges
As revealed from the self-appraisals and audit interviews of clients’ experiences and staff knowledge throughout the journey, strengthening the following aspects were required:
Related to Gaps in Knowledge and Skills
- Supporting parents to make an informed decision on infant feeding.
- Connecting with their babies before birth and developing a loving and positive parent-child relationship.
- Practising responsive feeding, especially responsive breastfeeding, according to the baby’s cues and mother’s desires.
- Considering options for continued breastfeeding and maximising breastmilk production.
Related to the Staff
- Increased workload and lack of staff time as a result of manpower shortage.
- Some staff showed resistance to change.
- Regular audits on knowledge and skills put stress on the staff.
- Staff expressed difficulties in disseminating key messages to clients.
Related to the Clients
- As opposed to the hospital setting where clients (parents) turned up only at a few points, such as antenatal check-up, delivery and immediate post-natal period, MCHCs served clients (parents and child) over a much longer period of time, spanning the antenatal, neonatal or even infancy period. It was laborious to provide congruent BFI services for them.
- There was a diversity of expectations from parents.
- Clients were not aware of the MCHCs’ working towards Baby-Friendliness.
Related to the Prevailing Mode of Service Delivery
- Traditionally, antenatal education took the form of one-way lecturing to a large audience, which did not provide opportunities for addressing personal issues.
- There was a lack of discussion of core messages such as responsive parenting, closeness and making informed infant feeding decisions at both antenatal and child health visits.
- While breastfeeding peer-support service had been commissioned since 2015, staff and clients were not familiar with the service.
“We have the privilege to be the companion of new parents from pregnancy through the important early years of parenthood.”
For the Staff
Our colleagues were an invaluable asset in implementing the standards. Instead of a “top-down” approach, it was crucial for all staff to gain a thorough understanding of the importance of infant feeding and early parent-child relationship in optimal childhood development. This provided a paradigm shift in moving towards Baby-Friendliness. The following strategies were adopted:
- Being inclusive: include all clinical and non-clinical staff such as allied health workers, clerical staff, workmen and security guards.
- Providing intensive training to equip our staff with knowledge and skills to implement the policy standards. This included updating the training curricula for each grade of staff, ensuring the training would enable them to perform their respective roles, and increasing the frequency of training such that all staff are trained within 6 months of joining the service.
- Updating or developing protocols and guidelines related to the policy standards, and communicating these to all staff.
- Treating rigorous audits as opportunities for consolidating the knowledge and skills of staff instead of an “examination”.
- Organising frequent communication with all staff e.g. orientation for new recruits within 2 weeks of joining the Service, clinic meetings for frontline staff, working group meetings.
- Encouraging exchange of ideas and experiences between the central BFI team and Pilot BFMCHCs staff.
For the Clients and Service Delivery
- Developing and enriching health education resources such as the booklet “Love, starts from Breastfeeding” 「愛·從母乳開始」 (2020 version) enabled our staff to use these tools to disseminate the core messages to clients.
Revamping the formats of health education to provide opportunities for staff to discuss with expectant mothers and new parents about feeding and caring for their babies:
- Antenatal Group Discussion (AN-GD): The key messages were presented in two small-group discussion sessions, which were conducted before and after 28 weeks of gestation. Multi-modal communication approaches such as booklets, visual aids, dolls, etc. were used to impress the core messages upon the pregnant women, and empower them to self-learn from the materials.
- Antenatal Individual Discussion (AN-ID): Structured discussions were conducted with pregnant women individually.
- Information on infant feeding, management of night feeds, safe sleeping practices and other relevant parenting issues was integrated into a structured discussion session during the child health visits. Parent cue-cards with key messages and QR codes linked to the relevant health education resources were developed.
- Organising frequent promotional activities of the Peer Support Service, such as visits by Peer Counsellors.
- Producing and displaying a plethora of publicity items to raise clients’ awareness of our mission on working towards Baby-Friendly MCHCs, e.g. the summary of Infant Feeding Policy, signs of welcoming mothers to breastfeed in MCHCs, activities of the Peer Support Service, etc.
Does Implementation of BFI in a Primary Health Care Setting have any Effect on Sustained Breastfeeding?
“The best has yet to come.”
Worldwide, implementation of BFHI in birthing hospitals has increased the breastfeeding initiation rates and, to a lesser extent, the duration of breastfeeding.5-6 Recently, Hong Kong has seen a rising breastfeeding rate on discharge from hospitals, which was 87.7% in the year 2018.7
According to the Breastfeeding Survey 2019 conducted by DH across all MCHCs on 2,218 babies who were born in 2018, the breastfeeding rates at 4 and 6 months were 55.7% and 46.5% respectively, while the exclusive breastfeeding rate at 4 months was 29.1%.8
In the year of attaining BFMCHC Designation, i.e. 2019, the mean breastfeeding rates of babies attending the 3 Pilot BFMCHCs at 4 and 6 months were 65.6% and 55.6% respectively, while the mean exclusive breastfeeding rate at 4 months was 34.9%. A higher continued breastfeeding rate was noted at the Pilot BFMCHCs, when comparing with other MCHCs providing routine care.
An increment of sustained breastfeeding rate was observed at the 3 Pilot BFMCHCs after three years of BFI implementation, with a mean increase of 2.5% (maximum 5.7%) in breastfeeding rate at 4 months of age, and a mean increase of 3.5% (maximum 5.4%) in breastfeeding rate at 6 months.
The results echoed with a pragmatic cluster quasi-randomised controlled trial in Norway, in which BFI in community health services increased the duration of any breastfeeding and exclusive breastfeeding until 6 months, compared with routine care.9
While there are positive changes at the 3 Pilot BFMCHCs, whether the same results can be expected in future BFMCHCs remains to be proven. Considering the diverse support from partnering birthing hospitals, the different socioeconomic backgrounds of clients and the varied competence of our staff, we need to watch out for the disparate challenges at different MCHCs when planning for the designation of future BFMCHCs. More thorough baseline appraisals and audits to identify the gaps at individual MCHCs and address them adequately are crucial.
The Way Forward
“We don't need a finish line.”
Through this long and arduous journey, a partnership between all administrative and frontline staff has been built. A strong team has been assembled to ensure that all babies get the best possible start in life, while committing to a continuous expedition of quality improvement.
Embracing the “Spirit” of Baby-Friendliness, the BFMCHCs view working according to the BFI standards as an enhanced form of supporting and caring for mothers and their babies, rather than a three-yearly examination for revalidation.
Baby-Friendly Initiative (BFI) goes beyond breastfeeding. BFMCHCs prepare expectant and new parents to care for and feed their infants in ways which support optimal health and well-being.
At the Pilot BFMCHCs, our focus was client-centric and operationally proficient whilst incorporating Infant Feeding Policy standards into our services.
Throughout the BFMCHC designation journey, several gaps were identified and key challenges emerged. Ongoing actions were required and coalitions from all administrative and frontline staff were built.
Embracing the “Spirit” of Baby-Friendliness and working according to the BFI standards are seen as an enhanced form of supporting and caring for mothers and their babies at the BFMCHCs.
For the note of References, please refer to the PDF version.
Annex 1: Stages of Baby-Friendly MCHC Designation
- Award of Certificate of Intent: Having registered the intention to work towards Baby-Friendly status within 5 years
- Award of Certificate of Commitment: Having formulated an Infant Feeding Policy with guidance for implementation of policy standards and action plan
- Award of Certificate of Level 1 Participation: Having put in place the mechanisms of implementation of the action plan and monitoring of policy standards
- Award of Certificate of Level 2 Participation: Staff having been assessed to possess the knowledge and skills to implement the Infant Feeding Policy
- Award of Baby-Friendly MCHC: Having satisfied the WHO criteria that the majority of mothers are prepared to care for and feed their infants appropriately
- Revalidation of Baby-Friendly MCHC: Having been assessed that standards of BFMCHC are being maintained or enhanced
Annex 2: Summary of the Baby-Friendly MCHC Infant Feeding Policy
- Have an Infant Feeding Policy (the Policy) that is routinely communicated to all health care staff.
- Train all health care staff in skills necessary to implement this policy.
- Support parents to make an informed decision of infant feeding, and build a close, loving and positive parent-child relationship. Inform all pregnant women about the benefits and management of breastfeeding.
- Carry out a full breastfeeding assessment at the early post-partum visit. Support parents to practice optimal responsive feeding.
- Advise mothers to breastfeed exclusively for six months and to provide safe and appropriate complementary foods, with continued breastfeeding for up to two years or beyond.
- Welcome breastfeeding mothers in the Centre.
- Refer mothers for additional professional care and/or community peer support as appropriate.
- Comply with the International Code of Marketing of Breastmilk Substitutes with subsequent relevant WHO/WHA resolutions.
Views expressed in this article are the author's and do not necessarily reflect the opinion or position of the BFHIHKA.
Editor-in-Chief: Dr Shirley Leung
All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.